New article published: The counseling, self-care, adherence approach to person-centered care and shared decision making: Moral psychology, executive autonomy, and ethics in multi-dimensional care decisions

A few days ago, an article by myself and three colleagues from philosophy, psychological safety research and pediatrics that's been accepted for a long time finally came online at the journal Health Communication's website. The article explores how standard accounts of how models for increased interaction and collaboration between patients and health care professionals – often termed patient or person centred care, and shared decision-making – fit badly to a broad group of patients; namely those whose care are mostly self-administered, who suffer vulnerable decision capacities and who exhibit a weakening adherence to decided care plans. In the article we illustrate the point with a study of adolescent diabetes care, based on video-taped consultation meetings between patients and health care professionals, and develop a general argument based on broadly recognised research in decision-making and moral psychology to revise the standard approach to person centredness and shared decision-making for this group of patients, focusing less on making shared rational autonomous decisions in health care meetings, and more on emotionally empowering patients and help them to develop virtues necessary to take responsibility for the self-care they agree on in collaboration with health professionals. Here is the abstract:

This article argues that standard models of person-centred care (PCC) and shared decision making (SDM) rely on simplistic, often unrealistic assumptions of patient capacities that entail that PCC/SDM might have detrimental effects in many applications. We suggest a complementary PCC/SDM approach to ensure that patients are able to execute rational decisions taken jointly with care professionals when performing self-care. Illustrated by concrete examples from a study of adolescent diabetes care, we suggest a combination of moral and psychological considerations to support the claim that standard PCC/SDM threatens to systematically undermine its own goals. This threat is due to a tension between the ethical requirements of SDM in ideal circumstances and more long-term needs actualized by the context of self-care handled by patients with limited capacities for taking responsibility and adhere to their own rational decisions. To improve this situation, we suggest a counseling, self-care, adherence approach to PCC/SDM, where more attention is given to how treatment goals are internalized by patients, how patients perceive choice situations, and what emotional feedback patients are given. This focus may involve less of a concentration on autonomous and rational clinical decision making otherwise stressed in standard PCC/SDM advocacy.

The article itself can be found here. For those who lack access to university libraries or subscriptions, a so-called postprint of the article – i.e. the author's finally submitted manuscript after peer review, but before editorial and type setting changes, pagination and so on – can be found here. Or you can contact me, to request a pdf of the published version.

Post Haiyan: A Very Brief Ethical Annotation Re. the Current Situation in the Philipines and Indonesia

In the aftermath of the monster typhoon Haiyan that hit especially hard in the Philipines and Indonesia recently, news have been continuing the past week of the tens of thousands of dead, many more injured and, of course long-term material and economic consequences which in turn will induce secondary and tertiary human harm, for instance through the social chaos emerging in the tracks of a destroyed civilisation. Reports are also coming, once again when catastrophes of this magnitude hit, of the willingness of nations and people all around the globe to help and assist in whatever way possible – acting on solidarity and compassion for the plight of others. Planes and ships with materials and competence are shuffled in the direction of need. This is how it should be, and the willingness to sacrifice masses of resources, time and own security for the sake of others makes me rejoice a bit over my own species in the middle of all the devastation.

However, one thing does not bring me joy, namely something that I in connection to the Haitian earth quake disaster in 2010 discussed in one of my earliest posts on this blog under the heading: How Our Compassion Reveals a Moral Abyss.

I point to it now, once again. Since it is relevant, since it is timely, since what now goes on shows how another order in this world could in fact have been possible – if it hadn't been for its weakest link: us.

Another Comment on Empirical Research Relating to Ethics and Morality: The Moral Behavior is not Necessarily so Moral at All

So, once again I have dared to post a small comment on an article in the mighty PLOS ONE open access science journal. Last time, as some of you may recall, it was a piece of psychology research claiming demonstrated predictive links (indeed!) between very particular emotional features and equally very particular types of moral judgements, to which I had some to my mind rather devastating comments based on the authors' apparent lack of insight into elementary ethical theory, quite besides the gap between the conclusion reached and the methodology applied. This time, it is once again psychology, albeit the thesis isn't quite as bold, but still interesting enough to probe. In Does “Science” Make You Moral? The Effects of Priming Science on Moral Judgments and Behavior, Christine Ma-Kellams and Jim Blascovich claim to have demonstrated through a series of experiments that people who think about (yes indeed, merely having in their thoughts) science are more likely to exhibit moral behaviour – the independently supported explanation of this being that science is regularly associated with positive moral features. Also here, however, the argumentation of the article is lacking and, in the end, deeply flawed due to lack of basic competence in ethical theory or moral philosophy. It is also flawed logically, independently of that, due to imprecise concepts being employed in the analysis. My conclusion is that while the study may confirm the rather trivial claim that people who think about moral features will engage more with (perceived) moral features in practical decision making and action, the engagement demonstrated in the studies may very well be immoral from the perspective of the moral features the subjects were aware of and/or engaged with. Read more here.

Utilitarianism and Empathy, or: Are Kantians Abnormally Empathic?

I just made some comments on a new psychology research article on the topic of how moral judgement link to emotional features in the journal PLOS ONE, entitled Low Levels of Empathic Concern Predict Utilitarian Moral Judgment. As with other articles of this type, I am a bit concerned by the sloppy use of ethical theoretical terminology among psychology and cognitive science researchers, as well as biased reportings of results. The secondary title of this little post is meant as a well-meant and humorous wink to the authors of the article and other researchers in the field of moral psychology as to what they may be unwittingly assuming when reporting their findings....

How our Compassion Reveals a Moral Abyss

Yesterday, BBC reported that the official death toll of the Haiti disaster is now 230 000, thus approaching the sum of lives claimed by the 2004 Indian Ocean Tsunami. Just as with the Tsunami, people and nations all over the world have reacted as we all expect from a standard of minimal decency: with horror and compassion put into action. Massive support programs have been set in motion to come to aid in the face of the unspeakable suffering and large numbers of voluntary individuals with useful skills have devoted time, resources and energy to the same end. Let it be that some of the initiatives have seen a bit odd, like the fixation of the US on tools of violence as the top priority when sending over 10 000 troops, or the outright bizarre, like this case that I covered in a former posting.

All of this is in line with the complex model of the human cognitive, emotional and motivational apparatus so famously sketched by David Hume in the 18th century: Besides experiencing and caring for ourselves, we have the evident natural ability to know the plight of others and the innate drive to be motivated by this knowledge. This picture still holds in most respects as modern psychological research and cognitive science advances - in fact, most of what is done in these fields build essentially on the basic psychological models of Hume. Similarly, modern science debunks the simplistic picture of human nature as essentially self-centered and egoistic in much the same way as Hume and his approximate contemporary Bishop Joseph Butler did: All of the tricks employed by advocates of psychological egoism to explain away evidence of non-selfish human motivation rests on a faulty picture of the human cognitive and motivational apparatus. What the psychological egoist would claim about our compassion and willingness to help in the face of the Haiti tragedy is that these things are mere side-effects of our striving for an emotional or material reward. Obviously, we may forget the material side - no one expects anything back from Haiti or its people; we even tolerate and understand that they are many times angry and disappointed at the result of the aid efforts when these fall short of meeting the needs. But the egoist has one more card up his sleeve, namely, the conjecture that we help because we strive for the feeling of satisfaction that being helpful provides. This argument, however, as Butler and Hume pointed out, puts the carriage in front of the horse, since it fails to take into account the source of the feeling of satisfaction: the fact that we need or want to come to aid. This is what motivates us - the emotional reward comes afterward. Modern cognitive science confirms this picture in terms of the biochemistry involved in motivation, emotion and feeling. The role of the neurological reward system is to uphold a system of motivation that in itself is not directed at achieving rewards or avoiding punishment, but at doing whatever it is one strives or wants to do. Only in special circumstances will our motivational attention be directed at the effects of the reward system (such as when we push ourselves to do something that we have a strong motivation not to do).

However, as Hume noted, our motivational capacities are at the same time rather arbitrary when it comes to our relations to other people, depending in turn on what associations between ourselves and others that are present in the mind. So, although we have that natural capacity for perceiving the emotional states of others that Hume called sympathy, and that enables us to identify the feelings, moods and affective states of others in terms of similarity and closeness to our own mental states, what we do in response to such perceptions is a rather open question. Moral reasoning, therefore, has to be about making such responses systematic and coherent, or at least to formulate an ideal pattern of motivational responses that we accept as desirable - the virtues in terms of prudence, benevolence and justice.

Since Hume's days, further factors influencing how we react to the plight of others have been mapped in psychological research, besides associations of similarity and closeness. For instance, various situational factors such as present mood is clearly influential and likewise regarding our sense of certainty with regard to our belief in our perception. Therefore, if I'm really pissed off when being asked to contribute to the Haitian cause I may end up not contributing just because of that, not because I fail to empathize with the victims. Or, if I doubt that my donation will really help these victims or that the situation is really as bad, this may counteract my willingness to give. Other well-known factors are assembled under the headline of framing; properties of the circumstances we are in that influence either our motivation or our tendency to act on it, such as threats or manipulations from other people. Moral thinking, ethical theory and our normative societal institutions (such as the legal system) have found various ways to get around all of these potential hurdles for moral reason to be able flourish. However, there is a further much more disturbing factor, having to do with the spatial-temporal denseness or concentration, and perhaps contrast to what one is accustomed to, of the perceived need.

Already during the aftermath of the Tsunami, UN aid officials pointed out that these sort of death numbers is what is ordinary due to poverty and starvation even in the absence of disastrous events such as storms or earthquakes. Rejoicing the willingness of people to give at the time, they expressed the hope that this willingness would continue in the face of this fact. This did not happen. Similarly, the Haitian death toll equals the number of children that die due to poverty every 10 days! Very many people are perfectly aware of this and there is no government anywhere that does not know these facts. But do they react proportionally to the way they react in the face of the Tsunami or Haiti tragedies? Of course not.

The explanation seems plain and straightforward. Our motivational system makes us prone to respond even to vast needs of many others when this collection of needs is experienced as spatio-temporarily concentrated and salient. Thus our admirable compassion for the victims of the Haitian disaster. But the flip side to that coin is that this property of our motivational system steers our motivation clear of being influenced by clear and certain knowledge of much much larger disasters when these are stretched out over larger portions of space-time and experienced as part of the ordinary. This is what makes us tolerate the ongoing processes that create this situation, some of which have been so well described by Thomas Pogge, rather than respond in a way similar to particular disasters such as the Tsunami or the Haiti earthquake.

Thus, the very source in human nature of the compassion that forms the root of our notion of morality is also the source of a virtual moral abyss. The challenge then seems to be: how do we get around this obvious lack of moral rationality without thereby sacrificing the sort of compassion we are already equipped with?